Purpose <p>Rectal cancer survivors are at risk of late adverse effects that impair quality of life. This study evaluates the cost-utility of a patient-led follow-up programme introduced in the Danish FURCA randomised controlled trial (RCT), aimed at improving patient outcomes and optimising healthcare resource use compared to standard hospital-based follow-up.</p> Methods <p>The cost-utility analysis was performed from a societal perspective over a 3-year horizon, incorporating healthcare costs, prescription drug use, productivity losses, all derived from Danish register data, and quality-adjusted life years (QALYs) derived from RCT-collected EQ-5D-5L data. Incremental cost-effectiveness was assessed using regression models and non-parametric bootstrapping, with subgroup and sensitivity analyses exploring heterogeneity in outcomes.</p> Results <p>A total of 336 patients were randomised to intervention and control groups. Over 3 years, mean healthcare costs were €40,208 for the intervention group and €41,190 for the control group (difference −€980; 95% CI −€7120 to €5159). Mean QALYs were 2.24 and 2.20, respectively (difference 0.028; 95% CI −0.106 to 0.163). The incremental cost-effectiveness ratio was −€35,048 per QALY gained, indicating dominance. Scatterplots of bootstrapped incremental cost-effectiveness ratios (ICERs) revealed iterations in all four quadrants, reflecting substantial uncertainty in both costs and effects. The probability of cost-effectiveness at a €30,000 threshold was below 70%.</p> Conclusions <p>Patient-led follow-up resulted in comparable QALYs and costs relative to standard hospital-based follow-up. The probability of cost-effectiveness at a conventional willingness-to-pay threshold reached up to 70%.</p> Implications for cancer survivors <p>Patient-led models may enable tailored delivery of specialist care to patients with greatest need, alongside balanced resource utilisation.</p>